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Monday, December 31, 2007

During one's medical training, the subject of organ transplantation becomes inescapable. For myself, I've encountered it at least twice, both during my two weeks on the liver transplant team, as well during my month on the renal service during my internal medicine rotation when I went to the transplant clinic. On the surface of it, organ transplantation is one of the great successes of modern medicine as well as seemingly straightforward ethical proposition. However, after closer examination it becomes clear that organ transplantation, while still being a net positive, is not as straightforward as one would like it to be.

The article "Desperately Seeking a Kidney" in the NYTimes highlights many of the main issues. The article is written by a psychiatrist who was seeking a kidney transplant. She describes what led her to be a candidate for organ transplantation, her time on the waiting list, her quests to solicit family, friends, and eventually strangers for a donation, and how the process affected both her and her potential donors. As medical students, we often deal with science of transplation, such as the immunology behind organ rejection, and the pharmacology

Organ transplantion is encouraged by many groups, often as the "gift of life." And while I still believe that organ donation is a positive action and should occur, I must confess my own misgivings about the process, especially given the experience in the article above. In my mind, the ideal solution would involve using stem cells or some other synthetic process to provide a replacement organ, making donation virtually obsolete. Of course, this is not reality (yet, anyway). So, we are left with donation as it is. As the author discusses, in the U.S., organ donations are "gifts" by definition, as there is no other legal way to obtain an organ. However, this leads to the "tyranny of the gift," as she describes: the burden the donor feels about being obligated to make a donation, the indebtedness the recipient may feel towards the donor. It should be noted that in the majority of the cases, organ donors view the experience positively, but it still important to consider the psychological aspect of donation.

To play devil's advocate for a moment though, I wonder why we impose a system of donation that requires that organs be a gift. I understand that potential for corruption, but the U.S. has a tradition of free markets, and there is a clear market here with a well-defined demand and supply. Of course, the market could not be completely 'free,' but it perhaps could be much less 'deregulated' than it is right. Currently, my understanding of the transplant system is that organs are listed on a list on the national registry (United Network for Organ Sharing, or UNOS). Potential recipients are ranked on a list; the ranking is based on various criteria that vary by organ. When a recipient is at the top of the list, they get the first shot at an organ. The donors are anonymous unless the recipient brings their own donor (such as a sibling). Now, imagine a similar system with anonymous donor-recipient pairings, but instead of giving a 'gift,' people are allowed to bid on organs. There are several benefits to this system, especially in light of the psychological issues discussed above. First, by offering compensation for organs, this could potentially expand the pool of potential donors, leading to more lives being saved. Second, by making the donation a transaction instead of a gift, it is possible that people would have less psychological hangups, and would view their donors as merely someone who they made a deal with, such as a car salesman, instead of their 'life savior.' Lastly, by putting a price on the organ, in theory, this would help curtail the black market for organs (okay, maybe not, but in theory, it would help).

The obvious problem here is that richer recipients will be better able to purchase an organ. However, perhaps this could be mitigated by utilizing the ranking system to weight dollars of people in greater need more highly. Still, I think most people would find the system unsavory, even if it were to lead to a net increase in organ donations. Perhaps a system utilizing a Dutch auction, or even one in which there is a fixed price for organs (such as the 'market' in place for the eggs of smart, young women with a college degree from an accredited institution) may increase the amount of donation.

In the end, I think the system in place, while less than ideal, is the best compromise between ideals and practicality. However, I think the notion of the market is interesting to consider because, depending on how science advances, we may one day have to ponder what the price of a synthetic organ should be.

Friday, December 28, 2007

I was recently discussing politics with a friend who is interested in health policy (and is also a med student). I realized that while I knew the general ideas that the candidates had, I wasn't too familiar with the specifics. I had tried previously to go to candidate websites, but I found myself getting bogged down, as each one had a different way of presenting their proposals. I asked my friend if there were any sites that simply compared the different policies. He directed me to health08.org, a website run the Kaiser Family Foundation. The site was easy to use, and let me compare any candidate's plan against any other candidate's plan.

As I tend to be liberal-leaning, I compared Senator Clinton's plan with Senator Obama's and Senator Edwards'. The comparison was fairly helpful, as it went through the plans and compared them on a point-by-point basis. Here's a summary of each plan, and my opinion of them:

Clinton: Every American is required to have coverage. To make this affordable, the plan will provide income-related tax subsidies. Plan options, both public and private, will be available through a "Health Choices Menu," which would be operated by the Federal Employee Health Benefits Program. Coverage through employers and public programs would continue. Employers of small businesses would receive a tax subsidy to offset their costs. Cost estimate: ~$100 billion, partly financed by rolling back tax cuts on those making over $250,000.

Obama: Every child will be required to have coverage. Employers will either have to extend benefits or contribute to a new public plan. A new "National Health Insurance Exchange" would facilitate enrollment in the new public plan. Employers would receive tax benefits to offset catastrophic costs. Cost estimate: ~$60 billion, partly financed by rolling back tax cuts on those making over $250,000.

Edwards: Every American is required to have coverage, with a goal of universal coverage by 2012. The plan would create nonprofit "Health Markets" in which public and private options would compete with each other. Expanded public funding for coverage of low income adults would also be provided for. There is no provision for employers. Cost estimate: ~$100 billion, partly financed by rolling back tax cuts on those making over $200,000.

So basically, the three candidates are providing the same healthcare plan with minor tweaks. I think Obama's would benefit from mandating coverage, but on the other hand, the plans with mandates do not technically guarantee coverage. Simply by saying you must be covered doesn't necessarily make it so. And what are we going to do if people choose not to buy? Fine them? Put them in jail? Maybe I am not understanding the mandate, but if they really want universal coverage, they should just expand the Medicare payroll tax deduction and call it the "National Healthcare" payroll deduction. Of course, that will never happen, but I'm jus' sayin'... Anyway, given what I've read, I think Clinton's and Edwards' plans sounds the best and have more detail. Obama's is good, but not as broad as theirs; however, his plan might be the one that is most realistically implementable. It is interesting to see his views on policy. I think Obama would be in support of mandates if crafting a system from scratch, but in this climate, perhaps he believes that a more incremental change is more feasible. I suppose I should admit a bias towards Obama, but I think any one of the candidates I mentioned above would be more than competent.

To be fair, here is what I understand of some of the other candidates' plans (in no particular order):

Giuliani: Healthcare reform 9/11. Now.

Paul: Ban healthcare as it was not mentioned in the Constitution.

Huckabee: Plan members will ask themselves, "What would Jesus do to heal himself?" instead of making claims.

Kucinich: Mars has healthcare for all, so why can't we? I was the first to propose the Martian plan.

Monday, December 24, 2007

Quick site update: I installed Photoshop this past week and started playing around with it. Heh, probably not the best software for the colorblind. Anyway, check out the new logo up top!

When I was on Family Medicine, my preceptor was involved with clearing people medically before they could fly. Usually it was fairly routine, but the one thing that differed from the typical physical is that he had to scrutinize their eyesight much much more than usual. One of the items he had to check was their color vision and make sure they were not colorblind.

There are several ways to do this, but the most popular method involves the Ishihara Color Test. We have all seen these before. They are basically dots of different sizes and colors that form a number that is visible only to people who are not colorblind. Here is an example (do you see a number below?):

Can you see the '74' in the middle in green dots? If not, that might mean you're colorblind (or illiterate, I suppose). The reason the dots are red and green is that this is the most common form of colorblindness with up to 10% of males having this disability. I mention 'males' because the gene for the red and green receptors are on the X chromosome, which means the inheritance is X-linked. There other forms of colorblindness like blue-yellow colorblindness, but this has autosomal inheritance and is less common.

However, even after one has diagnosed a patient, it is interesting to consider how they see the world. A colorblind person went ahead and tried to demonstrate through photographs, which I found interesting. I wonder though, when making the page, didn't the images look identical to him since he couldn't actually see the full color images like most of us can? How does he know he did it right? I guess there really no way to see the world exactly as he does, but it's still an intriguing approximation.

Friday, December 21, 2007

I recently read an article on the recently released Awake: The Movie. As the movie's IMDB profile notes, "The story focuses on a man who suffers "anesthetic awareness" and finds himself awake and aware, but paralyzed, during heart surgery. His young wife must wrestle with her own demons as a drama unfolds around them." Yawn. The only thing this movie has going for it is Jessica Alba. Heh, I just used that as an excuse to find that gallery. At any rate, the movie has some anesthesiologists concerned due to its portrayal of unscrupulous anesthesiologists torturing a patient and planning his murder during a procedure in which he has already been sedated but is still aware.

I have not seen this movie, nor do I plan to. The trailer I saw just sounded ridiculous. I sure hope no one out there is dumb enough to believe that this is commonplace. If so, that person probably also believes in The Force, hobbits, and the Matrix. How do movies like this even get made? Do they just draw ideas out of a hat? I remember when I was younger, people would always tell me to be "creative" by coming up with an idea, putting it in a bubble and then drawing lines to other bubbles and seeing what I came up with. At least, I think that was the idea. I imagine the bubble system here went something like:

Wednesday, December 19, 2007

I recently read an interesting article in the New York Times Magazine entitled Dr. Drug Rep. In it, a psychiatrist Dr. Daniel Carlat describes his experiences as a drug representative for Effexor XR over a year. He describes how he was initially recruited by Wyeth Pharmaceuticals, the producers of Effexor and his feelings about his first trip out as a drug rep. He describes the tactics the drug reps used to convince him to represent their drug, and what points they trained him to use to convince others. Dr Carlat's perspective is intriguing because he seems to be truly a man in the middle, as he neither a paid employee of a pharmaceutical company, nor a shrill PharmFree representative, touting a supposed moral high ground.

As medical students, we are secondary or tertiary targets for most reps (after physicians and residents). We stealthily sneak in to lunches, or are at times openly invited. We eat, casually listen, and sometimes come away with a pen. The reps vary: some ignore us, some politely greet us, and a few even try to make us converts early on. In any case, most medical students find the whole thing a bit comical but mostly harmless.

However, for those of us with a few ethical concerns, I have broken the issue down into point/counterpoints:

Point: Even though we are not the direct targets of the reps, we are still influenced by their pitches. Students will remember those drugs that are described more easily later on when they become practitioners. While we might not think we are being influenced, prescribing practices tend to show the contrary on average. Physicians are more likely to prescribe drugs that are detailed to them than drugs that are not. And the reps know this: Pharma links up drug sales info from local pharmacies to DEA numbers on lists sold to them by the AMA. As the article notes:

The American Medical Association is also a key player in prescription data-mining. Pharmacies typically will not release doctors’ names to the data-mining companies, but they will release their Drug Enforcement Agency numbers. The A.M.A. licenses its file of U.S. physicians, allowing the data-mining companies to match up D.E.A. numbers to specific physicians. The A.M.A. makes millions in information-leasing money.

Also, given the time constraints of such interactions, physicians are more likely to trust the nice-looking pharm rep who brought lunch instead of thoroughly investigating whether or not a particular drug is efficacious.Counterpoint: Free food

Point: At the end of the day, it is the patients who suffer when they are asked to purchase overpriced or inappropriate medications. As physicians, we have a fiduciary responsibility towards our patients to act in our patients' best interests. They trust us to do so, and their lives depend on it, quite literally in some cases. If we prescribe medications with competing interests at play, we do our patients a disservice.Counterpoint: Free pens, or even a laser pointer (Thank you, random dialysis dude)

Point: If one were to become involved as a representative for a drug, either by doing lunches or giving lectures, it is easy to lose one's objectivity in light of the significant additional income as well as prestige such events offer. Even by merely receiving gifts, there is some compromise of our integrity due to the norms of reciprocity deeply ingrained in our culture.Counterpoint: FREE STUFF!!!

Okay, in all honesty, I am still divided on this issue myself. I agree that the free stuff is effective (if it wasn't, why would Pharma spend so much money/time doing it?) and I agree that I most likely will be influenced. However, my economic senses chasten at the thought of limiting the marketing potential of a firm in a capitalist society. We allow gas companies, and car companies, and even alcohol companies to market their products in almost any manner possible. Why are drugs held to a different standard? All the other products I mentioned can also seriously harm individuals. Of course, those products do not involve a "fiduciary agent" like a physician who restricts their purchase, but still, why should that matter for marketing efforts? There seems to be inconsistency here, as we clearly trust physicians to prescribe drugs, yet are wary of how they may be swayed by representatives of the pharmaceutical industry.

To me, it seems like the current system cannot hold. I see one of two solutions. First, either physicians should get serious about this issue. To do so, they should petition the AMA to ban the sale of DEA information to pharmaceutical companies as well as ban detailing as a practice, ie ban pharm reps from entering their offices (as some physicians have done). However, this seems highly unlikely due to the entrenched interests who would have no reason to undergo such a radical change. My other thought would be to have all physicians basically make disclaimers to their patients about which representatives for which drugs have been in their office in the past 3-6 months, much like researchers must make disclaimers at the end of journal articles. By doing so, physicians would be free to decide whether or not to accept reps into their office, pharma companies could continue detailing, but I think the main difference would be that the "consumer" patient would be better informed about how their physician practices medicine and how their physician's prescription choice is or is not being influenced.

Just my two cents. Any comments one way or the other would be appreciated.

Heh, I can't imagine how a couple with 'penis captivus' would even make it to the ER, and once there, what would they do? I guess you could locally inject some kind of muscle relaxant like succinylcholine or something.

Monday, December 17, 2007

Often times in medical school, we are taught the algorithms for patient care. However, due to the volume of information, less care is taken to make sure students understand what exactly they are ordering when they work up a patient. Diagnostic imaging can be a particularly confusing area.

Historically, X-rays were the first mode of imaging and have been the primary mode for the past 100 years of medicine. A more recent development has been computed tomography, or CT. The CT basically takes a series of x-rays and integrates the data to create a more detailed image. X-rays and CTs effectively work on the same principle, which will be discussed in more depth in another post.

Magnetic Resonance Imaging (MRI) is a relatively new form of imaging. Although MRIs are becoming increasingly popular, their cost makes them prohibitive for broad use, so far. Some common questions med students might have when introduced to MRIs are: what is an MRI? How does it work? What is the difference between a T1 image? T2? FLAIR? As a med student, I claim no expertise in this area, but here is what I have learned.

...eh, on second thought, why reinvent the wheel? I can't do as good a job as some of the following sites:

Sunday, December 16, 2007

So, the title is a bit misleading. I did not scour through multiple peer-reviewed journals to find the best of what's new out there, but I did enjoy The New York Times Magazine's end of the year issue, which is focused on the great new ideas of 2007. Among them are many new discoveries and innovations within science and medicine. They are all short pieces, 2-3 paragraphs long, but they do a decent job summarizing what's new out there. Here are a few I found particularly intriguing:

Sunday, December 09, 2007

I've recently noticed that The New Yorker has excellent and engaging science and medicine articles. Of note are three recent pieces about Asperger's syndrome/autism, retroviruses, and preventing nosocomial infections.

In Parallel Play, the author discusses his lifelong struggle with Asperger's Syndrome. Of course, as a child, he did not know he had such a diagnosis, and so he went through life merely with a sense that he was different. It is interesting to see the prism through which he constructed his world in his own words. Often, as students and doctors, we only see a patient's symptoms, but rarely are we able to experience and understand the world exactly as they do.

In Darwin's Surprise, the author explores the role that retroviruses have played in human evolution. In fact, some scientists have been able to go back through the human genome and not find fragments of old viruses, but also recreate them! (Think Jurassic Park, but on a micro scale). These paleovirologists argue that the inclusion of these viruses into our DNA can provide protective benefits against such disease like AIDS. One thing I didn't know prior to reading this is that apparently some scientists argue that humans developed placentas and live birth (vs eggs) as a response to these retroviruses. Something to ponder...

In an article entitled The Checklist (which eventually forms the basis for the book titled The Checklist), Atul Gawande argues for the use of a simple checklist in order to save lives. He describes how the complexity of modern medicine has gone beyond even the most organized specialists and experts. However, by using something as simple as a checklist, medical care improved greatly in several hospitals and the number of line infections decreased dramatically. Written in Gawande's usual style, the article highlights the need for physicians to pay more attention to how exactly medicine is delivered, even if it takes away from the so-called 'art' of medicine.

While all the articles are somewhat lengthy, I think they're all good reads. Check out The New Yorker if you have a few minutes to spare.

Tuesday, December 04, 2007

War, huh, yeahWhat is it good forAbsolutely nothingUh-huhWar, huh, yeahWhat is it good forAbsolutely nothingSay it again, y'all-Edwin Starr, War

Until recently, one could probably say the same about the appendix. But, that's all the appendix wants: respek', yo. Well, now perhaps it can. This New York Times article explains one idea about an evolutionary role for the appendix, specifically, that the appendix serves to 'reboot' the gut if other flora are wiped out by diarrhea or dysentry. But, what if the appendix houses something like C. difficile? (Quick! How does one diagnose C. diff diarrhea? How does one treat it?)

Even if this idea stands the test of time, the appendix faces an uphill battle. Think about its name: the appendix. Something that's added on, tacked on the end, easily removed without affecting the main work (Q! What's the most common etiology of appendicitis?). Poor lil appendix. Even some cancers that start in the appendix don't get no 'respek' til they spread to the liver (Q! Name the cancer and some common symptoms).

Alright, I think I've stretched that out far enough... heh, and in the end, the appendix, what is it good for? Still pretty much nothing. Now, to start a (hopefully) new feature on the blog, here is Check It Out, where I link to something interesting I either found or have been reading about recently.Check It Out: Radiology Picture of the Day

My family medicine review book notes that some patient might refuse "sigmoidoscopy because they find it distasteful." I think they should find another gastroenterologist, because if their sense of taste is any way involved with their sigmoidoscopy, something's not right.

Same review book: "Physiologic fatigue is common in mothers of newborns, individuals who do shift work, athletes who overtrain, and in third-year medical students."

"We got an issue in America. Too many good docs are gettin out of business. Too many OB/GYNs are unable to practice their love with women all across this country." -President George W. Bush

From First Aid for Step 1: "Horner's syndrome clinically presents as Ptosis, Anhidrosis, and Miosis. Mnemonic: PAM is horny."

A joke I heard from a friend: An internist, psychiatrist, surgeon, and pathologist go duck hunting. They go out into the blind and wait for a duck. The internist is up first and sees a bird fly over. He looks out and says, "I think it's a duck... but it could be a quail, or pheasant, or dove, or maybe..." and the duck flies away. The pyschiatrist is up next. She sees a bird fly over and thinks, "There's a duck! But... does it know it's a duck? Is it self-actualized as a duck?" and the bird flies away. The surgeon is up next. He sees a bird fly over, and *BOOM* goes his gun. He then says, "Pathologist, go over there and tell me if it's a duck."

Monday, December 03, 2007

So, here's a little story I heard from a friend that I found both interesting and educational. I cannot vouch for its veracity, but like Stephen Colbert, my gut says it's true.

Back in 18th century France, French mothers were very concerned about who their daughters consorted with. In order to save them from men of suspect character who may be intent upon sowing their wild oats, the mothers would warn their daughters to avoid men with bobbing heads. The question for modern day medical students is, why?

The answer? The bobbing head, also known as De Musset's sign, is a sign of severe aortic regurgitation caused by syphilitic aortitis. Had the daughters flaunted their mother's warnings and flirted with these loathsome Lotharios and perhaps gone in for the proverbial French kiss, they may have also noted a bobbing uvula, also known as Muller's sign.

The only question I have is, why did French mothers know about syphilis? Hmm...